BSN 366 EXIT HESI updated -Questions with 100%
Correct Answers | Verified | Latest Update 2026
A client fell in the bathroom when left unattendeded by the unlicensed assistive personnel
(UAP). Which information should the nurse include in the client's health record?
The client fell sustaining a fracture to the left hip.
A young adult visits the clinic reporting symptoms associated with gastritis. Which
information in the client's history is most important for the nurse to address in the teaching
plan?
Snacks on foods with very high salt content on a daily basis
The nurse reviews the physician1s orders for clonazepam and gives the medication as
ordered. What nursing interventions are appropriate for the client starting clonazepam?
Select all that apply.
A. Screen for orthostatic hypotension
B. Provide oral care at least twice a day
C. Monitor calcium levels
D. Assess mental status regularly
E. Assist the client to the bathroom
F. Have an opioid agonist at the bedside
A. Screen for orthostatic hypotension
B. Provide oral care at least twice a day
,D. Assess mental status regularly
E. Assist the client to the bathroom
What other treatments might be helpful for this client? Select all that apply.
A. Phototherapy
B. Administration of lithium
C. Consciousness-raising
D. Cognitive behavioral therapy
E. Animal therapy
F. Electroconvulsivetherapy
D. Cognitive-behavioral therapy
E. Animal therapy
A client with a history of type 1 diabetes mellitus {DM) and asthma is readmitted to the
unit for the third time in two months with a current fasting blood sugar (FBS) is 325 mg/dL
(18 mmol/L). The client describes to the nurse of not understanding why the blood glucose
level continues to be out of control. Which intervention{s) should the nurse implement?
{Select all that apply.)
Blood Glucose Reference - 74 to 106 mg/dL {4.1 to 5.9 mmol/L)
A. Have the client demonstrate technique used to monitor blood glucose levels.
B. Evaluate the client's asthma medications that can elevate the blood glucose.
,C. Ask the client if they want a different manufacturer's glucose monitoring device.
D. Have the client describe a typical day at work, home, and social activities.
E. Determine if the client is using a new insulin-led learning administration.
A. Have the client demonstrate technique used to monitor blood glucose levels.
B. Evaluate the client's asthma medications that can elevate the blood glucose.
D. Have the client describe a typical day at work, home, and social activities.
E. Determine if the client is using a new insulin-led learning administration.
A client who weighs 65 kg receives a prescription for lorazepam 44 mcg/kg intravenously to
be administered 20 minutes before a scheduled procedure. The medication is available in 2
mg/mL vial. How many mL should the nurse administer? (Enter numerical value only. If
rounding is required, round to the nearest tenth.)
1.4 mL
Calculate total dosage required: 44 mcg/kg * 65 kg = 2860 mcg.
Convert mcg to mg: 2860 mcg 7 1000 = 2.86 mg.
Divide by concentration: 2.86 mg 7 2 mg/mL = 1.43 mL.
An infant who weighs 22 pounds receives a prescription for amoxicillin 20 mg/kg/day by
mouth in divided doses every 8 hours. The bottle is labeled, "Amoxicillin for Oral
Suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with each
dose? {Enter numerical value only. If rounding is necessary, round to the nearest tenth.)
1.3 mL
, A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet
count of 25,000/mm3 {25 x 109/L). Which intervention is most important for the nurse to
include in this client's plan of care?
Reference Range: Platelet Count 150,000 to 400,000/mm3 {156 400 x 109/L)
Assess urine and stool for occult blood.
An older client is taken to the clinic by the spouse, who appears extremely worried. The
spouse reports to the nurse that the client started to not make any sense and asked to visit a
brother who has been dead for many years. Which action{s) should the nurse take? (Select
all that apply.)
A. Obtain the client's tympanic temperature measurement.
B. Review the client's current food and medication allergies.
C. Ask if the client is experiencing any pain with urination.
D. Encourage increasing the intake of high-protein foods
E. Determine if the client has recently experienced a fall.
A. Obtain the client's tympanic temperature measurement.
C. Ask if the client is experiencing any pain with urination.
E. Determine if the client has recently experienced a fall.
The nurse is triaging several children as they present to the emergency room after a school
bus accident. Which child requires the most immediate intervention by the nurse?
An 11-year-old with a headache, nausea, and projectile vomiting.
Correct Answers | Verified | Latest Update 2026
A client fell in the bathroom when left unattendeded by the unlicensed assistive personnel
(UAP). Which information should the nurse include in the client's health record?
The client fell sustaining a fracture to the left hip.
A young adult visits the clinic reporting symptoms associated with gastritis. Which
information in the client's history is most important for the nurse to address in the teaching
plan?
Snacks on foods with very high salt content on a daily basis
The nurse reviews the physician1s orders for clonazepam and gives the medication as
ordered. What nursing interventions are appropriate for the client starting clonazepam?
Select all that apply.
A. Screen for orthostatic hypotension
B. Provide oral care at least twice a day
C. Monitor calcium levels
D. Assess mental status regularly
E. Assist the client to the bathroom
F. Have an opioid agonist at the bedside
A. Screen for orthostatic hypotension
B. Provide oral care at least twice a day
,D. Assess mental status regularly
E. Assist the client to the bathroom
What other treatments might be helpful for this client? Select all that apply.
A. Phototherapy
B. Administration of lithium
C. Consciousness-raising
D. Cognitive behavioral therapy
E. Animal therapy
F. Electroconvulsivetherapy
D. Cognitive-behavioral therapy
E. Animal therapy
A client with a history of type 1 diabetes mellitus {DM) and asthma is readmitted to the
unit for the third time in two months with a current fasting blood sugar (FBS) is 325 mg/dL
(18 mmol/L). The client describes to the nurse of not understanding why the blood glucose
level continues to be out of control. Which intervention{s) should the nurse implement?
{Select all that apply.)
Blood Glucose Reference - 74 to 106 mg/dL {4.1 to 5.9 mmol/L)
A. Have the client demonstrate technique used to monitor blood glucose levels.
B. Evaluate the client's asthma medications that can elevate the blood glucose.
,C. Ask the client if they want a different manufacturer's glucose monitoring device.
D. Have the client describe a typical day at work, home, and social activities.
E. Determine if the client is using a new insulin-led learning administration.
A. Have the client demonstrate technique used to monitor blood glucose levels.
B. Evaluate the client's asthma medications that can elevate the blood glucose.
D. Have the client describe a typical day at work, home, and social activities.
E. Determine if the client is using a new insulin-led learning administration.
A client who weighs 65 kg receives a prescription for lorazepam 44 mcg/kg intravenously to
be administered 20 minutes before a scheduled procedure. The medication is available in 2
mg/mL vial. How many mL should the nurse administer? (Enter numerical value only. If
rounding is required, round to the nearest tenth.)
1.4 mL
Calculate total dosage required: 44 mcg/kg * 65 kg = 2860 mcg.
Convert mcg to mg: 2860 mcg 7 1000 = 2.86 mg.
Divide by concentration: 2.86 mg 7 2 mg/mL = 1.43 mL.
An infant who weighs 22 pounds receives a prescription for amoxicillin 20 mg/kg/day by
mouth in divided doses every 8 hours. The bottle is labeled, "Amoxicillin for Oral
Suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with each
dose? {Enter numerical value only. If rounding is necessary, round to the nearest tenth.)
1.3 mL
, A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet
count of 25,000/mm3 {25 x 109/L). Which intervention is most important for the nurse to
include in this client's plan of care?
Reference Range: Platelet Count 150,000 to 400,000/mm3 {156 400 x 109/L)
Assess urine and stool for occult blood.
An older client is taken to the clinic by the spouse, who appears extremely worried. The
spouse reports to the nurse that the client started to not make any sense and asked to visit a
brother who has been dead for many years. Which action{s) should the nurse take? (Select
all that apply.)
A. Obtain the client's tympanic temperature measurement.
B. Review the client's current food and medication allergies.
C. Ask if the client is experiencing any pain with urination.
D. Encourage increasing the intake of high-protein foods
E. Determine if the client has recently experienced a fall.
A. Obtain the client's tympanic temperature measurement.
C. Ask if the client is experiencing any pain with urination.
E. Determine if the client has recently experienced a fall.
The nurse is triaging several children as they present to the emergency room after a school
bus accident. Which child requires the most immediate intervention by the nurse?
An 11-year-old with a headache, nausea, and projectile vomiting.
